For those trying to grow their urgent care business, conversations around payer contracting and credentialing (CC) can often be overwhelming and seem contradictory to the mission of On-Demand Care. Tammy Mallow, our resident Experity advisor on all things CC says she often finds herself being the perceived as a “dream killer” when educating owners to the inner workings of this process.

Established groups often expect the payer rules to be the same as they were years ago, only to find they may not be able to add a new location to current contracts, or they must now credential all providers—even per diem providers. They are shocked to find they may now be required to have a physician on site, or no longer have a physician on site, or pass accreditation to renew a contract…it goes on and on.

Considerations When Growing and Expanding in the Same Market

  • Provider type credentialing changes
  • Fee schedules and contracted rates
  • Services allowed or excluded
  • Oversite requirements
  • Accreditation or site visits
  • Ability to add locations to existing contracts

Differences to Anticipate and Explore If Moving Into a New market or a New Start-Up

  • Types of agreements available
  • Barriers to network access
  • Credentialing criteria
  • Oversite requirements
  • Accreditation or site visits
  • Contracted rates (average by payer and differences in type of provider)

In both scenarios, one of the most frequent questions addressed, per Ms. Mallow, is whether a provider currently, or previously, credentialed or enrolled with a payer must go through the credentialing process again.

Sadly, the answer most of the time is Yes. The rules do vary by payer, provider type, and market, so it is always very important to understand that one size does not fit all—even within a market. For example, Blue Cross Blue Shield in State A could require providers to credential each time they join or start a new practice while Aetna in State A would only require some type of demographic update form to add a provider.

Tammy Mallow, Experity advisor, says the best rule of thumb is to assume previous provider credentialing in another location does not have an impact on credentialing in a new location.

So, how about a little good news (or at least some better news)?

The timeframe to credential a new provider has historically been completely at the will of the payer, and still is in many cases, as is the decision on when a provider would be considered effectively in-network and able to see and bill patients accordingly. That date is usually the date the credentialing committee approves, which can be 90 days or longer from the time the application was submitted. During this time, the provider likely has not been seeing patients, or only a select few. Or worse, seeing them as out-of-network and not being reimbursed much, if at all.

As urgent care continues to influence the healthcare industry, combined with the effect that provider shortages are having on patient care, some states have started to consider or introduce legislation around credentialing timeframes and even requiring payers to pay claims retroactively. While this is a start, and is very good news, most payers still do not pay retroactively, do not offer any type of provisional credentialing, and can take months to credential a new provider.

The moral of this story is that you cannot assume anything is the same in the world of urgent care contracting and credentialing. The work of a CC team is so much more than filling out applications. Doing your homework, surrounding yourself with a strong CC team, and staying current are the keys to success!

Credentialing and Contracting: What to Expect When Expanding

Monte Sandler

Executive Vice President, Revenue Cycle Management of Experity (formerly DocuTAP and Practice Velocity ).
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